Discussing the HRT dilemma

What a shame that headlines never tell the whole story! They don't and this invariably causes worry, and results in poor medical treatment. For several weeks, female patients have been asking me what they should do about hormone replacement therapy (HRT). This concern has been triggered by newspaper headlines linking HRT to complications, but the news is not as shocking as it appears to be. And, unfortunately, many women are making the wrong decision about HRT.

The Women's Health Initiative (WHI) reported that the long-term risks of HRT, such as the increased risk of breast cancer and cardiovascular disease, outweighed the benefits, the decreased risk of hip fractures and colon cancer.

The headlines failed to stress that there were only very small increases in breast cancer, heart attack, stroke and blood clots among HRT users. For instance, there were eight more cases of breast cancer and seven more cardiovascular problems for every 10,000 women per year of use.

The risk is much greater for women who are obese, smoke and don't exercise.

Dr. Robert Reid is professor of obstetrics and gynecology at Queens' University, Kingston, Ont., and a leading expert on HRT. He reports several interesting facts, totally missed by the headlines, in the October issue of The Journal of Obstetrics and Gynecology of Canada.

In this study, women who had been on HRT prior to enrolling showed a slight increase in breast cancer after five years -- but there was no increase in breast cancer among women who had never used HRT before enrolling in the study. Dr. Reid points out this ironic, but important, fact. Past studies show that women who have breast cancers detected while taking HRT have a better survival rate than those not using these hormones.

NO NEED FOR PANIC

Also largely unnoticed, women who had had a hysterectomy and only required estrogen were not advised to stop it because, so far, there is no evidence that risks outweigh benefits. Estrogen has now been used for 60 years by millions of women. Good sense tells you that if estrogen were a major cause of breast cancer there would be a raging epidemic.

It also needs to be underlined that women who use HRT have a decreased risk of osteoporosis and hip fractures.

So what should women do? First, there's no need for panic and hasty decisions, because there are several alternatives.

It's not sensible for newly-menopausal women to tolerate severe symptoms. The study shows that taking Premarin 0.625 milligrams (mg) daily along with 2.5 mg of MPA up to four years is not harmful.

Some women who have been on HRT for years may wish to stop it. These patients can gradually wean themselves off it and may notice no change in their well being. But if flushes, insomnia and a desire to kick the boss return, they can go back on HRT. It doesn't make sense to put up with a wretched quality of life when the risks from HRT are so small.

Women who discontinue HRT must realize they've lost one important way of preventing osteoporosis, a common and severe complication of aging. This means adequate calcium intake, vitamin D and exercise must be ensured. If bone mineral density studies show early signs of this disease doctors can prescribe Fosamax or Evista, a new non-hormonal drug that prevents and treats osteoporosis.

Another danger has gone unnoticed. Estrogen plays a vital role in keeping a healthy vaginal lining. Year after year, I see patients who suffer painful sex when a small amount of Premarin vaginal cream (estrogen) would cure this problem in days.

Since this news hit the headlines, I've seen several patients who decided to stop HRT. The flushes, insomnia and increased irritability have returned with a vengeance. Their only solution is to go back on hormones.

The primary message for women is to never, never forget the importance of quality of life and well being. And that scary headlines never tell the whole story.